Health Insurance (Positron Emission Tomography) Facilities Determination 2009

Administered by Department of Health, Disability and Ageing

Legislation au F2009L03207 Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health and Ageing

 

Health Insurance Act 1973

 

Health Insurance (Positron Emission Tomography) Facilities Determination 2009

 

 

Subsection 3C(1) of the Health Insurance Act 1973 (the Act) provides, in part, that the Minister may, by writing, determine that a health service not listed in the diagnostic imaging services table (the Table) shall, in specified circumstances and for specified statutory provisions, be treated as if it were so listed.  The Table is set out in the Health Insurance (Diagnostic Imaging Services Table) Regulations 2008 which are remade each year.

 

A determination made under subsection 3C(1) is a legislative instrument for the purposes of the Legislative Instruments Act 2003 (see subsection 3C(4) of the Act and paragraph 6(d) of the Legislative Instruments Act 2003).

 

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009 (the Determination) revokes and replaces the Health Insurance (Positron Emission Tomography) Facilities Determination 2008. 

 

Positron Emission Tomography (PET) is a form of nuclear medicine used mainly to determine the presence and severity of cancers, neurological conditions and cardiovascular disease.  PET images reveal the chemistry of organs and other tissues such as tumours.  A radiopharmaceutical that gives off signals is injected into the patient and its emissions are measured by a PET scanner.

 

The Determination allows for the payment of Medicare benefits in relation to PET services provided by a limited number of providers with eligibility agreements with the Commonwealth.  The Determination maintains the current availability of Medicare benefits for nineteen items relating to PET services and deletes eleven items relating to oesophageal, gastric, and head and neck cancer.  The content of nine of these items will be found in six new items in the Health Insurance (Positron Emission Tomography) Determination 2009.   This means that from 1 July 2009, these items will be available to all eligible PET facilities, rather than only to those providers with eligibility agreements with the Commonwealth.

 

The two items removed from the Determination relating to gastric cancer were not recommended for continued funding by the Medical Services Advisory Committee (MSAC).

 

Details of the Determination are set out in the Attachment.

 

The Determination commences on 1 September 2009.

 


Consultation

 

The Department wrote to the facilities on 13 November 2008, advising them that oesophageal items have been approved for public funding by the Minister, but that gastric cancer had not been recommended for public funding and would, therefore, be removed from the Facilities Determination.  This means that no facility in Australia will be able to access gastric items on the MBS from 1 July 2009.

 

DIAGNOSTIC SERVICES BRANCH

DEPARTMENT OF HEALTH AND AGEING

JUNE 2009

 

 

 


ATTACHMENT

 

NOTES ON SECTIONS TO THE DETERMINATION

 

Section 1

 

Section 1 provides that the Determination may be cited as the Health Insurance (Positron Emission Tomography) Facilities Determination 2009.

 

Section 2

 

Section 2 provides that the Determination commences on 1 September 2009.

 

Section 3

 

Section 3 provides that the Determination revokes the Health Insurance (Positron Emission Tomography) Facilities Determination 2008.

 

Section 4

 

Subsection 4(1) defines terms used in the Determination.  

 

Section 5

 

Section 5 specifies the circumstances in which the Determination applies.  These circumstances are:

  • that a written agreement between the owner or operator of the PET facility and the Commonwealth relating to the rendering of the service by the facility is in place; and
  • the service is rendered pursuant to a written request made by a specialist or consultant physician (other than the practitioner who renders the service) that the service was necessary and whose patient the person was.

 

Section 6

 

Subsection 6 (a) provides that a relevant service specified in the Schedule to the Determination shall be treated for the purposes of all provisions of the Act, regulations made under the Act, the National Health Act 1953 and regulations made under the National Health Act 1953 that make provision in respect of professional services or medical services, as if it were both a professional service and a medical service.

 

Subsection 6(b) provides that a relevant service specified in the Schedule to the Determination shall be treated for the purposes of all provisions of the Act, regulations made under the Act, the National Health Act 1953 and regulations made under the National Health Act 1953 that make provision in respect of professional services or medical services, as if there were an R-type diagnostic imaging service in the diagnostic imaging services table that related to the service and specified a fee in respect of that service being the fee specified in the Schedule.

 


Section 7

 

Section 7 provides that the provisions specified in section 7 shall have effect as if a relevant service and the items that relate to a relevant service by virtue of section 6(b) were also specified in those provisions specified in section 7.

 

The Schedule

 

The Schedule sets out the relevant services and assigns to the services the applicable item number, item descriptor and fee.

Overview

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009 was enacted by the Minister for Health and Ageing to address the problem of ensuring appropriate funding for Positron Emission Tomography (PET) services in Australia, specifically in the context of cancer diagnosis and treatment. PET is a vital imaging technique used to determine the presence and severity of various conditions including cancers, neurological conditions, and cardiovascular diseases. The 2009 Determination was issued under subsection 3C(1) of the Health Insurance Act 1973, which allows the Minister to determine that a health service not listed in the diagnostic imaging services table should be treated as if it were listed, provided certain conditions are met. The objective of the Determination is to facilitate the payment of Medicare benefits for PET services by a limited number of providers who have eligibility agreements with the Commonwealth. It also ensures the continued availability of Medicare benefits for specific PET-related services while discontinuing benefits for certain cancer-related PET services that were not recommended for continued funding by the Medical Services Advisory Committee. This Determination came into effect on 1 September 2009, replacing the previous 2008 Determination.

Scope and Application

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009 applies to services provided by PET facilities that have entered into an eligibility agreement with the Commonwealth, specifically targeting the provision of Medicare benefits for PET services. The geographic reach of this Determination is national, affecting all PET facilities across Australia. The Determination specifies the circumstances under which PET services will be eligible for Medicare benefits, including the requirement for a written agreement between the facility and the Commonwealth and a written request by a specialist or consultant physician that the service was necessary and for their patient. The Determination revokes the previous 2008 version and incorporates changes to the list of eligible PET services, with some services relating to oesophageal, gastric, and head and neck cancer being removed due to recommendations by the Medical Services Advisory Committee. This Determination commences on 1 September 2009, ensuring that the specified PET services are available for Medicare benefits from that date. The application of the Determination is extended through subordinate instruments which provide details on the specific services, their descriptors, and associated fees.

Key Provisions

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009, made under subsection 3C(1) of the Health Insurance Act 1973, establishes the conditions under which PET services will be treated as listed in the diagnostic imaging services table (Sections 1-2). This means that the services can attract Medicare benefits under the Act. Section 3 of the Determination revokes the previous 2008 version and Section 4 defines key terms such as 'relevant service' and 'PET facility'. Section 5 outlines the circumstances for the application of the Determination, requiring a written agreement between the PET facility and the Commonwealth and a written request from a specialist or consultant physician confirming the necessity of the service (Section 5). Section 6 specifies how relevant services are treated under the Act and related regulations, effectively including them in the diagnostic imaging services table and assigning them an item number, descriptor, and fee (Section 6). The obligations imposed by the Determination on PET facilities include entering into a written agreement with the Commonwealth and ensuring that services are rendered based on a written request from a specialist or consultant physician (Section 5). Facilities must also comply with the terms set out in the Schedule, which specifies the relevant services, their item numbers, descriptors, and fees (Section 6). Any changes or updates to the services or fees must be communicated and agreed upon by the Department of Health and Ageing. Failure to comply with the requirements of the Determination can result in legal consequences. The specific offences, penalties, or consequences for breach are not detailed in the Determination itself but would generally fall under the provisions of the Health Insurance Act 1973 and related legislation. Penalties for non-compliance could include fines, revocation of eligibility to provide services, or other administrative actions. Given the nature of health services, severe or repeated breaches might also lead to criminal charges, depending on the circumstances and the specific provisions of other relevant laws. The maximum penalties would be dictated by the applicable laws under which the breach occurs.

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